More than half of new cancer treatment regimens involve an oral route of administration because oral drugs are more manageable and convenient for patients. However, oral medications pose challenges with regard to patient adherence.
At the ONS 40th Annual Congress in Orlando, FL, Pamela K. Ginex, EdD, RN, OCN®, nurse researcher, Memorial Sloan Kettering Cancer Center in New York, and Susan M. Schneider, PhD, RN, AOCN®, FAAN, associate professor, director oncology nursing specialty, Duke University in North Carolina, discussed tools to improve patient adherence.
Oral chemotherapy agents were first introduced in the 1940s and 1950s following the discovery of signaling pathways. To date, a number of agents have been approved in oral form, with 50% of therapies currently in development being oral. These agents are advantageous because they provide convenience for the patient, do not require intravenous access, can achieve sustained drug levels, result in minimal disruption to daily life, and are often preferred by patients. However, oral agents also distance the patient from the provider, change the way patients are monitored, result in lacking prescription and administration, and shift the responsibility of care to the patient.
In general, one-third of patients do not take their medications as prescribed, although improving adherence can result in $300 billion saved in healthcare costs. The specific rates of nonadherence for oral cancer treatments remain unknown, but a variety of breast cancer studies have indicated adherence rates between 53% and 93%.
Medication nonadherence can result in side effects caused by toxicities, compromised healthcare provider communication, increased emergency room use and/or hospitalization, decreased survival, and tumor growth. For patients with cancer, not following medication regimens can lead to unnecessary disease progression, complications, reduced functional abilities, lower quality of life, and premature death. Therefore, “Adherence is critical to successful treatment outcomes,” according to the presentation.
According to the World Health Organization, five factors may contribute to nonadherence.
Patient-related factors include language, culture, religious beliefs, cognitive impairment, comorbidities, drug-to-drug interactions, gender, psychopathology, and knowledge. Condition- and therapy-related factors include disease type and stage, knowledge of disease, and side effects related to the disease and treatment. Clinician-related factors include treatment beliefs, provider and patient relationship, guidelines, continuity of care and patient follow-up, providing education and information, and communication and decision-making.
The following are predictors of poor adherence.
- Presence of psychological problems (i.e., depression)
- Cognitive impairment
- Inadequate follow up or discharge planning
- Side effects
- Patient lack of belief in treatment
- Poor provider─patient relationship
- Barriers to care or medications
- Missed appointments
- Complexity of treatment
- Cost of medications and/or copayment
The speakers noted, “There needs to be a nursing presence in all phases of oral cancer treatment. We need to be proactive and not reactive.” Oncology nurses can contribute by rethinking practice, remembering that education and communication are key, and intervening in medication adherence.
The speakers discussed a survey of 577 oncology nurses that found that 51% had specific policies, procedures, and resources for patients on oral chemotherapy. They also found that the most commonly cited barriers to medication adherence included cost (81%) and adverse effect (27%). As a result, nurses should provide thorough education and repeated teaching to improve patient safety, adherence, and self-monitoring for side effects.
Interventions include behavioral practices (e.g., pill diaries, postcard reminder for refills, blister packs, setting cell phone alarms), electronic reminders (e.g., applications, text messaging, automated voice recording), and support (communication, reassurance, monitoring for depression, family support, and follow up).
In conclusion, appropriate administration of oral agents requires a patient-centered approach with a collaborative relationship between patients and providers that includes education assessment, symptom and side-effect monitoring, and a coordinated approach to care.
Ginex, P.K., & Schneider, S.M. (2015). Oral therapy: Underadherence, overadherence, and everything in between. Session presented at the ONS 40th Annual Congress, Orlando, FL, April 25, 2015.